Background Moral distress is a far-reaching problem for nurses in different settings as it threatens their health. Aim This study examined which situations lead to moral distress in home-care nursing, how and with which consequences home-care nurses experience moral distress, and how they cope with morally stressful situations and the resulting moral distress. Research design A qualitative interview study with reflexive thematic analysis was used. Participants and research context We conducted semi-structured interviews with 20 home-care nurses in Germany. Ethical considerations (...) The study was approved by the Data Protection Office and Ethics Committee of the German Federal Institute for Occupational Safety and Health. Findings Twenty (14 female and 6 male) home-care nurses were interviewed between April and August 2023 at their chosen location. The situations leading to moral distress were inadequate care of the person in need of care, not being able to protect one’s health, extended responsibility for the entire care arrangement, work–privacy conflicts, and conflicts between the understanding of care or professional ethics and the performance and billing system. The nurses experienced moral distress as they worked alone and provided care in the patient’s territory. Short- and long-term strains with destructive cognitions, negative emotions, physical symptoms, and health consequences were reported. They faced challenges in coping with moral distress on institutional and individual levels. Conclusions In cases of tension between the service and billing system and the understanding of these nurses’ care services, moral distress is unavoidable. Alternative forms of organization and billing modalities, such as payment by time and the expansion and refinancing of service, should be implemented. The latter relates to systematic case and ethics meetings. Further, a transfer of medical activities, such as the prescription of wound material to registered nurses, could prevent morally stressful situations and improve patients’ quality of care. (shrink)